ALL OF THE FOLLOWING INFORMATION THAT YOU PROVIDE TO US THAT IS PERSONAL IN NATURE WILL BE KEPT STRICTLY CONFIDENTIAL

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1. Have you ever experienced any symptoms that you feel are related to your cell phone use? Yes/No
a. If yes, what is/was your most troubling symptom?
b. Have your daily activities been affected? Yes/No
c. Why do you feel these symptoms are associated with your cell phone use?
d. Have you sought medical attention for these symptoms? Yes/No
__d1. If yes, have you received a diagnosis? Yes/No
__d2. If yes, please specify
e. If yes, have you been hospitalized because of this? Yes/No
f. Are you currently experiencing this symptom? Yes/No

2. Are you currently a cell phone user? Yes/No
a. If no, what were your reasons for stopping? Check all that apply:
a1. Lack of use
a2. Cost
a3. Health concerns
a4. Other specified

3. What type of cell phone did you use when you had your symptoms?
a. Analog
b. Digital
c. PCS
d. Dual mode (both analog and digital)
e. Don't know

5. How long have or did you use this phone that you believed caused your symptoms?
a. Less than 1 year.
b. 1 to 3 years.
c. 4 to 6 years.
d. More than 6 years.

6. On average how many minutes do you or did you use your phone each month that you believed caused your symptoms?
a. Very infrequently (emergency use or less than 30 minutes per month)
b. 30 to 120 minutes per month
c. 121 to 500 minutes per month
d. 501 to 1000 minutes per month
e. Greater than 1000 minutes per month

7. What year did you begin using the phone that you believed caused your symptoms?

8. Gender M/F

9. Age

10. Zip Code

11. State of residence

12. Country of Residence

13. May we contact you if further information is necessary? Yes/No
Name:
Address: